Neetu Singh, Sugandha Jauhari

1Department of Obstetrics and Gynaecology, DR. Ram Manohar Lohia Institute of Medical Sciences, Lucknow, India

2Department of Community Medicine and Public Health, King George Medical University, Lucknow, India

ABSTRACT

Objective: To study the knowledge, attitude, and practice of pregnant women regarding transmission and preventive measures of COVID-19 from mother to child and to determine the reasons for vaccine hesitancy.

Methods:This observational cross-sectional knowledge, attitude,and practice study was conducted among pregnant women of any trimester, attending the antenatal care out-patient department of a tertiary care hospital in Lucknow from October 2020 to March 2021. All the participants were interviewed using a pretested semistructured questionnaire for desired information. Reasons for vaccine hesitancy were also asked to assess their unwillingness to get vaccinated.

Results:Totally 652 pregnant women were included and 91.3% were aware that COVID-19 spread through contact with an infected person and 85.3% knew that COVID-19 spread by respiratory droplets. Of pregnant women, 95.7% perceived that social distancing and wearing a proper mask were effective ways to prevent SARS-CoV-2 infection and 96.8% of the pregnant women wore masks regularly when going out. Of pregnant women, 79.0% were hesitant to get vaccinated. The most common reason was that COVID-19 vaccine can harm the developing fetus(77.5%) and was not very safe in pregnancy (75.0%).

Conclusions:Of the pregnant women, 22.92% have unsatisfactory knowledge regarding COVID-19, 35.63% have negative attitude and 19.93% have poor practices, indicating that there are still gaps in awareness, and majority of them are unwilling to get vaccinated. Good awareness will help prevent the occurrence of future COVID-19 waves in India.

KEYWORDS: COVID-19; Pregnant women; Awareness;Transmission; Preventive measures; Vaccine hesitancy

1.Introduction

The novel coronavirus disease 2019 (COVID-19) is caused by severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2),and has already taken on pandemic proportions, affecting the whole world in the minuscule of time[1-3]. The whole world is experiencing the menace of this pandemic in form of a series of waves occurring at unrelated intervals including India. This is attributed to the fact that the dense population of India fails to adhere to the COVID-19 appropriate behaviour due to which the pandemic not only affects the people but also the health system[4,5].

The most important factor in preventing the spread of the virus locally is to empower the citizens with the right information and take advisories being issued by the Ministry of Health &Family Welfare, Government of India regularly. To guarantee the final success, people’s adherence to these control measures is essential, which is largely affected by their knowledge, attitudes,and practices towards COVID-19 under knowledge, attitude, and practice theory[6,7].

Pregnant women form a vulnerable group due to various physiological changes in pregnancy putting them at a higher risk for contracting a severe infection[8]. Indian Council of Medical Research (ICMR) has reported that pregnant and post-partum women were worst affected in the second wave of COVID-19 infection in India as compared to the first with the more symptomatic and severe form of the disease and poor fetomaternal outcomes[9]. Since the safety and efficacy of COVID-19 vaccines have not been studied to date in any vaccine trial and there is the restriction of various drugs during pregnancy, the preventive measure is the only effective way to curb the COVID-19 in them[10]. For this, adequate knowledge, attitude, and practice regarding COVID-19 transmission and prevention is required.

Very few studies have been conducted among pregnant women for COVID-19 in India. Seeing the paucity of evidence from this region, our study will unravel this gap in their knowledge and understand the reasons for vaccine hesitancy among them, which will be beneficial in the implementation of vaccination guidelines for pregnant women. Therefore, the study was planned to study the knowledge, attitude, and practice of pregnant women regarding transmission and preventive measures of COVID-19 from mother to child and to determine the reasons for vaccine hesitancy.

2.Subjects and methods

2.1. Study design and setting

It was an observational cross-sectional study conducted among the pregnant women attending the antenatal care out-patient department of Obstetrics and Gynaecology Department of a tertiary care centre in Lucknow, India.

2.2. Study participants and eligibility criteria

The study included currently pregnant women aged 15-49 years of any trimester who were cooperative and gave informed verbal and written consent for data collection. Those pregnant women who were not cooperative during the interview were excluded.

2.3. Data collection tool and mmeasurements

Data were collected for 6 months i.e., from October 2020 to March 2021. The purpose of the study was explained to all the study participants and confidentiality of information was maintained throughout. They were then subjected to a pretested semi-structured questionnaire to collect information about their knowledge, attitude, and practice regarding COVID-19.

The questionnaire consisted of two parts–demographic details and a knowledge, attitude, and practice (KAP) tool. Demographic variables included age, religion, education level, occupation, place of residence (urban or rural), and socioeconomic status (Modified BG Prasad classification 2021). The knowledge section consisted of two parts–13 questions regarding clinical symptoms, prevention,and control of the disease. Evaluation of attitude of the pregnant women was done by 5 questions assessing viewpoints on social distancing, control of COVID-19, and lockdown to prevent the spread of COVID-19. Regarding the assessment of practice, 9 questions were asked regarding the idea of grocery stocking,preventive measures during the lockdown, and relationships with family and friends. The responses to knowledge questions were rated on a 3 Likert Scale as yes, no and don’t know. Further scoring was done as 1 for saying yes and 0 for no or don’t know and reverse scoring for negative questions. The different types of response scales were determined based on the forms and appropriateness of questions asked. Similarly, attitude and practice questions had responses as yes or no and scoring was done as 1 for the positive attitude and good practices and 0 vice-versa. The final knowledge, attitude and practices score was sum of score of the number of items in the tool and mean was calculated. If the score of the study participant was more than the mean, then KAP was adequate and satisfactory. The content as well as face validity of the questionnaire was done on 100 participants and then modifications were done. The content validity indice (S-CVI)was 0.482 and it was acceptable. The COVID-19 KAP tool was also reliable with a Cronbach alpha value of 0.857. There was no multicollinearity observed between the items in the three domains of KAP.

Reasons for vaccine hesitancy were asked from the pregnant women who showed their unwillingness to get vaccinated. All the interviews were conducted by the same researcher and all efforts were made to minimize bias in the study. All the forms were reviewed for completeness and the woman was contacted again via telephone in case of inadequate information.

2.4. Sample size

For sample size estimation, finite population correction was applied to the sample size formula, i.e. n = NX/ (X + N–1) where,X= Za/2×p(1-p)/d, taking p as the proportion of individuals with adequate knowledge about COVID-19 (value was 80.64%[11],then at 99% confidence interval and power of 80%, the minimum sample size (n) required was 652 pregnant females.

2.5. Sampling technique

The tertiary care centre where the study was conducted was one of the largest government medical colleges and research centres in the district of Lucknow and was also catering as a referral centre for nearby districts like Barabanki, Unnao, Kanpur, Lakhimpur,etc of the state of Uttar Pradesh, India. Pregnant women of any trimester attending the antenatal care of out-patient department of this centre were selected using systematic random sampling. With a sampling interval of 4, every fourth pregnant female fulfilling the inclusion criteria was enrolled in the study.

2.6. Statistical analysis

The data were analyzed using the licensed Statistical Package for Social Sciences (SPSS Inc., Chicago,Illinois, USA) version 22.0 software purchased by the institute (license number: DOEJWLL).A descriptive summary using frequencies, percentages, graphs, and cross tabs was used to present the study results. Mean knowledge,attitude, and practice scores were calculated. If the score was more than the mean, then knowledge was satisfactory, the attitude was positive, and practice was good. The scoring and calculation of proportions was done on SPSS.

2.7. Ethical consideration

This study was approved by the Institutional Ethics Committee of Dr. RMLIMS, Lucknow, India (IEC No. 61/20).

3.Results

3.1. Baseline characteristics of the study participants

More than two-thirds (69.2%) of the study participants were of the age group 26-35 years. A majority of them belonged to the rural area (72.7%) and were Hindu by religion (71.8%). 26.2%, 28.4% and 25.9% females had a primary, secondary, and intermediate level of education. Almost two-thirds (62.1%) of the pregnant females were homemakers. More than one-third of them (35.6%)belonged to the lower middle socioeconomic class. Almost half of the study participants (49.8%) were in the second trimester and 37.9% and 1-3 living children (Table 1).

Table 1. Sociodemographic characteristics of pregnant women (n=652).

3.2. Awareness regarding the transmission and preventive measures of COVID-19 from mother to child

A majority (75.8%) of the study participants knew that COVID-19 was caused by a virus. Almost 91.3% were aware that COVID-19 spread through contact with an infected person and 85.3% knewthat it spread by respiratory droplets. Maximum pregnant females knew that fever (96.8%) and difficulty in breathing (97.7%) were early signs of COVID-19. 93.4% of females were aware that COVID-19 spread from symptomatic cases although almost half of them had reported that it also spread from asymptomatic cases or from both. Nearly all (99.5%) of the pregnant women knew that COVID-19 could be prevented by maintaining social distancing.Only two-thirds knew that isolation of contacts was an important measure to prevent COVID-19 spread (64.3%). The majority of the pregnant women (96.8%) answered that diabetes led to more dangerous COVID-19. Only 80.2% knew that period of isolation for COVID-19 was 14 days. More than half (52.6%) reported that eating citrus fruits and 41.3% said that steam inhalation could prevent COVID-19. All the pregnant women answered that pregnant women were at more risk of contracting COVID-19 infection (100%) (Table 2).

Table 2. Knowledge regarding transmission and prevention of COVID-19.

3.3. Attitude of study participants regarding prevention of COVID-19

A majority (96.3%) of the pregnant women had the attitude that the novel coronavirus could be prevented by regular hand washing, 81.9% stayed at home to prevent the COVID-19, and 95.7% of pregnant women had the perception that social distancing and wearing a proper mask were effective ways to prevent COVID-19 infection. Most of the pregnant women (96.9%) felt that COVID-19 could be contracted during pregnancy during delivery or postpartum period. 80.8% of pregnant females perceived that sanitization of hospitals, public places, and buildings could prevent COVID-19 (Table 3).

Table 3.Attitude regarding transmission and prevention of COVID-19.

3.4. Practices of pregnant women regarding prevention of COVID-19

A majority (96.8%) of the pregnant women wore masks regularly when going out. Although 21 pregnant females were still not wearing the mask on going out. Maximum females (93.9%)maintained a social distance of 2 feet while visiting crowded places. 90.6% of females washed vegetables, fruits, and groceries after buying. 91.7% females washed hands regularly to prevent COVID-19. Still, 54 females were not practicing hand washing properly. Almost four-fifths (81.9%) practiced staying at home to prevent COVID-19 (Table 4).

Table 4. Practices regarding transmission and prevention of COVID-19.

3.5. Vaccine hesitancy among the study participants

Out of 652 pregnant women, 515 were unwilling to get vaccinated for COVID-19. The most common reasons were that vaccines could harm the developing fetus (77.5%), were not very safe in pregnancy (75.0%), would complicate the pregnancy at the time of delivery (58.3%), would cause COVID-19 disease, and would transmit to the baby (52.5%), could cause congenital abnormalities in the baby inside the womb (22.1%), could cause mental retardation in the baby (17.5%), could kill the baby in utero (10.5%)and no effective studies reporting about the efficacy of COVID-19 vaccine among pregnant women (3.5%) (Table 5).

Table 5. Reasons for vaccine hesitancy among the pregnant women (n=515).

3.6. Knowledge, attitude, and practice scores of the study participants

Overall, 77.08% of pregnant females had satisfactory knowledge about COVID-19. However, only two-thirds(64.37%) had a positive attitude toward preventing COVID-19 and finally 80.07% were having good practices for preventing COVID-19 (Figure 1).

Figure 1. Knowledge, attitude, and practices of the pregnant women in the study.

4.Discussion

COVID‐19 infection is a public health problem and adequate knowledge among the populace is essential for its management.The second wave of COVID-19 in India was a huge public health crisis and resulted in a major toll of cases with severe disease and consequently caused many deaths. Only COVID-19 appropriate behaviour will be able to prevent the expected third wave. Currently, COVID-19 is endemic in India with spurt of cases in small clusters in different parts of the country at different time intervals. The major variant circulating in the population is Omicron. Cases reported are generally mild to moderate with very low proportion of severe cases. Vaccination plays a vital role in reducing the severity of disease. A pregnant female is susceptible to COVID-19 infection and severe disease, so prevention is the best approach for managing COVID-19 in them. It has been demonstrated that adequate knowledge is a prerequisite for the establishment of preventive belief, forming a positive attitude, and promoting a positive practice of disease[12].

The present study has observed that 77.08% of pregnant women had satisfactory knowledge regarding COVID-19 disease,64.37% had a positive attitude and 80.07% had good practices which will help prevent the occurrence of the expected third wave in India. This agrees with the study conducted by Kaur et al among Indian pregnant women who also observed satisfactory knowledge and positive attitudes among most of the pregnant women[8]. Other researchers from Iran (90%), Pakistan (93.2%),China (90%), and Tanzania (84.4%) have also reported adequate and higher knowledge regarding COVID-19 as compared to our findings[13-16]. The difference may be associated with variations in socio-demographic characteristics, study setting, and study participants. The other possible reason might be disparities in the presence of trained human resources and health care systems of the countries to create awareness regarding the pandemic[17].

In our study, 75.8% of pregnant females knew that COVID-19 is caused by the virus, but this was slightly less than the findings by Anikwe et al who reported the same among 88% of pregnant females[12], and more than that by Degu et al who reported that 64.2% knew that COVID-19 was caused by a virus[17]. This variation is subjected to the different levels of education among the pregnant females and different study settings as urban areas report better knowledge due to good access to multimedia and other facilities. Kasemy et al conducted a knowledge, attitude, and practice study among the general population of Ethiopia and found that 100% of the study participants knew that COVID-19 is a viral disease[18]. Being a low resource country, the awareness among the population was good. A majority of the pregnant women in our study knew that COVID-19 spreads mostly through contact with the infected person (91.3%) and secondly by respiratory droplets(85.3%). This is similar to the findings of Degu et al who reported that 88.2% of pregnant females knew the same[17]. In our study,96.8% and 97.7% of pregnant females respectively knew that early signs of COVID-19 are fever and difficulty in breathing and this was in concordance with studies by other researchers in lowincome countries like Ethiopia (88.58%) and Ghana (85.6%) as well as from India (98%)[8,17,19]. The adequate knowledge could be attributed to robust efforts by the government of India in spreading information and increasing awareness regarding COVID-19 since the beginning of the pandemic[8].

All the study participants (100%) in our study reported that pregnant women are at more risk of contracting the COVID-19 disease. This percentage was higher than the study by Degu et al where only 49% of pregnant females said that they think that they can contract the disease[17]. This knowledge is important because pregnancy is a physiological immunosuppression state and makes the female vulnerable to contracting the COVID-19 which can be fatal for the in-utero fetus[8]. In the study by Kaur et al among pregnant women, 71% of females replied that there is no proven treatment for COVID-19, and only 13% of females knew vaccine was a cure[8]. So, this is an area where the government must work actively in creating awareness regarding the vaccination for COVID-19.

More than 90% of the pregnant women had a positive attitude that COVID-19 can be prevented by hand washing, avoiding crowded places, maintaining social distance, and wearing a proper mask. This is slightly more than in studies by Anikwe et al (82%),Quansar et al (83%) Lee et al (81%)[12,20,21]. This difference might be due to the time of the studies conducted in which information delivery and awareness creation programs about the pandemic are ongoing and improving from time to time. For this reason, practices were expected to be low at the beginning of the pandemic. As far as practices were concerned, most of the pregnant women practiced COVID-19 appropriate behaviour, and this is in concordance with studies by other researchers[12,20,21]. Good practices are indicative of the robust efforts of the government in creating awareness regarding the disease through all the platforms among the general population[8].

Vaccine hesitancy was observed in 79% (515/652) of the pregnant women in this study. Ghoncu Ayhan et al have reported that 63% of pregnant females in Turkey were unwilling to get vaccinated and the most common reason was concern regarding their efficacy[22].In a US-based study, it was observed that compared to other women of reproductive age, pregnant participants were six times more likely to delay COVID-19 vaccination and twice as likely to decline[23]. The key factor for hesitancy is that pregnant women were excluded from clinical trials of COVID-19 vaccines, despite being at increased risk of developing severe illness from COVID-19 causing adverse feto-maternal outcomes[24]. Several studies have also shown a small, 2% to 3% risk of vertical transmission and the presence of viral RNA in the breast milk of mothers infected with COVID-19, but the evidence is conflicting and nonconclusive[24,25].

There are some limitations of the study. Firstly, being a hospitalbased study, it is difficult to generalize the results among all the pregnant women of Lucknow. Secondly, conducting a study by interviewing the people does not reflect their proper practices and a qualitative design will be beneficial in understanding the magnitude of this problem. Lastly, the social desirability barrier might have influenced the responses of the respondents. However,all efforts were made to reduce all such biases.

In conclusion, of the pregnant women, 77.08% have satisfactory knowledge regarding COVID-19, 64.37% have positive attitude and 80.07% have good practices, which will help prevent the occurrence of future COVID-19 waves in India. However, there are still gaps in awareness, and majority of them are unwilling to get vaccinated. There is a need to strengthen the health policies that encourage interpersonal discussion of COVID-19 preventive measures among pregnant women to improve their accuracy of knowledge, attitude, and practices for COVID-19 prevention and enhance a further reach of information to those who may not have access to radio and television in remote communities. This will enhance the uptake of COVID-19 vaccination during pregnancy.

Conflict of interest statement

The authors declare there is no conflict of interest.

Funding

The study received no extramural funding.

Authors’contributions

Neetu Singh and Sugandha Jauhari contributed to participating in conception and designing of the study, conducting the literature review and collecting data. Sugandha Jauhari did the data analysis and drafting of the manuscript. Neetu Singh contributed to interpretation of results and revision of manuscript. Both the authors approved the final version of manuscript.

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